Novus Health Limited Quality Account 2011/2012 · 2.1.2 Clinical priorities for 2012 forward/13...

Quality Account 2011/12 Author- Fiona Stainthorpe, Clinical Manager-May 2012

1

Novus Health Limited Quality Account

2011/2012 Providing services on behalf of the NHS


2

Contents Part 1-Statement on Quality 1 Executive summary - Statement from Chairman 3 What is a quality account? 3 Part 2 2.1 Priorities for improvement 4 2.1.1 Review of clinical priorities 2011/12 (looking back) 4 2.1.2 Clinical priorities for 2012 forward/13 (looking forward) 4 2.2 Mandatory statements relating to the quality of services provided 5 2.2.1 Review of services 5 2.2.2 Clinical audit 7 2.2.3 Goals agreed with commissioners 8 2.2.4 Statement from the Care Quality Commission 8 2.2.5 Statement on data quality 10 Part 3-Review of Quality Performance 3.1 Patient safety 11 3.2 Clinical effectiveness 12 3.3 Patient experience 12 Part 4-Conclusion 16


3

1. Executive summary Statement from Chairman When in 2007 a group of local GPs decided to set up a provider company our aims at the outset included a commitment to quality. We felt that by using well qualified senior local clinicians we should be able to match or improve on the quality of existing local services whilst at the same time providing services more efficiently and more cost effectively. The quality account that follows demonstrates that our clinicians and management team have done an excellent job in delivering our services with quality and patient experience at the forefront. I believe it would be difficult to beat figures such as these and our challenge will be to continue to maintain such a high standard as our range of services expands. I am confident that we have the attitude, experience and determination to rise to this challenge. Martin Shutkever-Chairman Novus Health Limited What is a quality account?

Quality accounts are annual reports from organisations, like Novus Health, that provide NHS healthcare services. The accounts are about the quality of the services provided for NHS patients and are intended as a public document.Novus Health has measured the quality of the services provided by looking at:

patient safety

Novus Health takes patient safety extremely seriously and our aim is to minimise the risk to patients wherever possible. We aim to do this by ensuring that staff are trained appropriately, equipment works safely and any incidents are reported and investigated so that any lessons can be learnt.

patient feedback about the care provided

Novus Health is keen to hear from patients regarding their experience of care with us. We continually aim to improve our services and patient feedback is one such opportunity to understand how services are received from the patient's point of view.

the effectiveness of treatments that patients receive

Novus Health ensures that all patients who receive treatment have the opportunity to report on whether they feel there has been an improvement in their symptoms following their treatment. Novus Health aims to review patients where appropriate and provide follow-up care if required.


4

2.1 Priorities for improvement

2.1.1 Review of clinical priorities 2011/12(looking back)

Registration with CQC - achieved

Establish Choose and Book as preferred method of referral for elective care -achieved

Undertake comprehensive review of carpal tunnel assessment and treatment service - achieved

Undertake comprehensive review of vasectomy service - achieved

Review and revise the electronic clinical information system for the vasectomy service - achieved

Review and revise the electronic clinical information system for the carpal tunnel assessment and treatment service - achieved

Review methods of gathering patient’s views - achieved

Implement audit cycle - achieved 2.1.2 Clinical priorities for 2012/13 (looking forward)

Patient safety

Improve information given to patients on the consent process

Ensure all clinical staff continue to undertake appropriate essential training such as how to safeguard adults and basic life support

Infection prevention audit to be included in audit cycle

Ensure all clinical staff provide information relating to their blood borne virus status

Introduce training placements for physiotherapy students Clinical effectiveness

Continued compliance with the CQC Standards of Quality and Safety

Undertake review of carpal tunnel assessment and treatment service to ensure that actions required from 2011/12 have been implemented

Undertake a review of sperm sample protocol to ensure compliance with best practice.

On-going monitoring of sperm sample return rates, to ensure maximum compliance from patients, by implementing a reminder system for those patients that don’t provide samples at appropriate times

Review outcomes for tennis elbow treatment (physiotherapy)

Review outcomes for treatment of shoulder/rotator cuff lesions (physiotherapy)

Trial of a short-term course of Pilates for long-term/chronic lower back pain (physiotherapy)

Develop acupuncture as a treatment option (physiotherapy)


5

Patient experience

Redesign the Novus Health website to make it more user friendly for both patients and referrers

Implement patient satisfaction questionnaires for carpal tunnel assessment and treatment service

Review patient satisfaction questionnaires on a quarterly basis for: o One stop Vasectomy service o Carpal tunnel assessment and treatment service o Carpal tunnel decompression service o Physiotherapy service

Telephone review of patients at two days and six weeks post carpal tunnel surgery provides an opportunity for real-time feedback on the quality of service provided

Ensure improvements are made following any complaints received

Ensure all appointments made with patients are arranged over the telephone to ensure maximum choice for patient regarding venue, date and time and minimise DNAs

Explore innovative ways to gain patient feedback including real - time responses over the telephone or website

2.2 Mandatory statements relating to the quality of services provided 2.2.1 Review of services During 2011/12 Novus Health provided two NHS services:

Carpal tunnel assessment and treatment service

One stop vasectomy service Novus Health worked with a subcontractor, Hodgson Physiotherapy Services, to provide a community physiotherapy service to the patients in NHS Wakefield District. Novus Health worked as a subcontractor with Mid Yorkshire Hospitals (NHS) Trust to deliver a community cardiology service. The income generated by the NHS services reviewed in 2011/ 2012 represents 100% of the total income generated from the provision of NHS services by Novus Health for 1st April 2011 to 31st March 2012. Activity Data (2011/12) Carpal Tunnel Assessment and Treatment Service

First consultation (334)

Number of patients treated with Steroid Injections (201)

Number of patients treated with Splints (151)


6

Carpal Tunnel Decompression Service

Number of patients undergoing surgery (185)

Conversion rate for surgery-55% One Stop Vasectomy Service (291 patients) Physiotherapy service (5948 patients) The services provided by Novus Health were all commissioned by NHS Wakefield District. Human Resources % Sickness (0.5%) Total number of days lost (5 out of 884 days) % Appraisal (80%) includes permanent staff; zero hour’s staff and Consultants (aim for 100% in 2012/13) Mandatory Training (90%) includes permanent staff, zero hour’s staff and consultants Patients Formal Complaints:

Carpal Tunnel Assessment and Treatment service (0.08%)

One Stop Vasectomy service (0%)

Physiotherapy service (0%)


7

2.2.2 Clinical audit During 2011/12 Novus Health carried out a number of clinical audits to ensure that the quality of care provided to patients meet the required standards. In relation to all the services provided by Novus Health, each had at least one audit completed and all had at least one record keeping audit completed.

Service Audit Results


Audit of the GP assessors care between June-Dec 2011

80% patients were followed up by assessors at 6 weeks - need to aim for 95%. Repeat audit in Dec 2012


Audit of clinical procedures-Jan-Dec 2011

47.5% of patients are managed surgically. 80% of patients are initially managed conservatively prior to referral for surgery. Repeat audit in December 2012.


Record keeping audit 77% of assessment records were completed appropriately. Payment on outcomes recommended. Repeat audit in December 2012


MRSA Screening prior to surgery

100% patients screened for MRSA. 3% required MRSA decolonisation therapy prior to surgery

Physiotherapy service Discharge summary audit-Dec 2011

Aim to improve consistency of information provided to GPs - repeat audit Dec 2012

Physiotherapy service Record keeping audit-Oct 2010-April 2011

100% records documented informed consent-repeat audit in October 2012.

Vasectomy service Record keeping audit-Jan 2011-June 2011

100% records had discharge summaries sent to patient’s GP

Vasectomy service Semen sample return rates audit Jan 2011-Mar 2011

64% return rate (in line with Mid Yorkshire Hospital (NHS) Trust

Vasectomy service Semen sample return rates audit April 2011-June 2011

61.2% return rate (in line with Mid Yorkshire Hospital (NHS) Trust

Vasectomy service Early (Technical)Failure rates audit

0%-0.7% National rate-1%

Community Cardiology Service Audit of completion of episodes of care-Jan 2011-April 2012

84% of episodes of care were completed within 6 months. 3% patients required on - going referral to Cardiology


8

2.2.3 Goals agreed with commissioners Use of the CQUIN payment framework: During 2010/2011 the income generated by Novus Health was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. Although Novus Health did not take part in 2011/2012, it will generate some income in 2012/2013 from CQUIN payment. CQUIN payment will be aligned to the following goals:

1 Patient Experience Patient experience of outpatient services to inform continued service development and involvement

40%

2 MRSA Screening MRSA screening and prescribing for positive MRSA cases for day case surgery patients

20%

3 Incident Reporting Demonstrate robust incident management system which reflects lessons learnt and improvements made

40%

2.2.4 Statement from the Care Quality Commission Novus Health registered with the Care Quality Commission in April 2011. The following conditions of registration apply:

Diagnostic and screening procedures

Surgical Services

Novus Health underwent an unannounced inspection by CQC in November 2011. Their current overall judgement was that ’Novus Health was not meeting one or more essential standards. Improvements are needed’. ‘There are minor concerns with Outcome 12’. ‘Patient satisfaction questionnaires reviewed at inspection show that satisfaction with the service (Carpal Tunnel Decompression Service) being provided is high.’ Although this was the overall judgement, the following standards were reviewed and commented on.


9

In Summary: Outcome 1: people should be treated with respect: involved in discussions about their care and treatment and able to influence how the services run. People are treated with respect and supported in a way that upholds their dignity

Overall, we found that Novus Health was meeting this essential standard. Outcome 4: People should get safe and appropriate care that meets their needs and supports their rights People receive safe and appropriate care that meets their needs and supports their rights

Overall, we found that Novus Health was meeting this essential standard. Outcomes 7: People should be protected from abuse and staff should respect their human rights Processes are in place to ensure staff are aware of safeguarding procedures through a programme of training. A procedure is in place for protecting vulnerable adults.

Overall, we found that Novus Health was meeting this essential standard. Outcome 12: People should be cared for by staff who are properly qualified and able to do their job The information reviewed at inspection shows that some elements of recruitment practice are not being followed. References are not routinely being sought as part of recruitment and blood borne virus status of staff is not being checked. There are minor concerns with Outcome 12.

Overall, we found that Novus Health was not meeting this essential standard. As a result compliance action has been made.

N.B. Compliance action is the action needed to achieve compliance with the essential standard. This action is taken if people are not at immediate risk of serious harm. Novus Health has developed an action plan which has been submitted to the CQC demonstrating actions that will be taken to achieve compliance. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care People are treated at a service which has systems in place to monitor and assess the outcome for people.

Overall, we found that Novus Health was meeting this essential standard. A copy of the full report is available on the CQC website.


10

2.2.5 Statement on data quality Novus Health holds a contract with NHS Wakefield District and currently provides the following reports: Carpal Tunnel Assessment and Treatment service

Monthly Patient Schedule

Monthly Activity report

Quarterly activity report

18 week target report

One Stop Vasectomy service



Quarterly activity report

18 week target report Physiotherapy service



Although Novus Health did not submit any records to the Secondary Users’ Service, for inclusion in the Hospital Episodes Statistics during 2011/12, an internal audit has demonstrated that the number of patients with a valid NHS number was 100%.The number of patients with a valid General Medical Practice code was 100%. Information Governance Toolkit attainment levels Novus Health has used the toolkit provided by ‘NHS Connecting for Health’ that assists in measuring the quality of the IT data systems, standards and processes used in the organisation to collect data. Successfully completing this toolkit leads to a statement of compliance (IGSoC) which enables Novus Health to access electronic information systems run and managed by the NHS. Novus Health’s information governance assessment report score overall score for 2011/12 was 67% and was graded ‘green’ (satisfactory). Clinical coding error rate Novus Health was not subject to the Payment by Results clinical coding audit during 2011/12 by the Audit Commission.


11

3. Review of Quality Performance 3.1 Patient safety

Patients are routinely asked to comment on the cleanliness of the facilities used for our services. Below are the results for the following services:

Carpal Tunnel Decompression Service (March 2011-December 2011)

Excellent 62.50% Very Good 28.10%

Good 9.40% Fair 0.00% Poor 0.00% No answer 0.00%

Good or better 100% One Stop Vasectomy Service (Aug 2011-March 2012)



Good or better 100%

Community Physiotherapy Service (Oct 2011-Dec 2011)



Good or better 99%

100% of patients undergoing carpal tunnel decompression surgery were screened for MRSA. 3% of patients required MRSA decolonisation therapy prior to surgery. No reported cases of infection post-surgery.

100% of patients undergoing carpal tunnel decompression surgery and vasectomy surgery signed a consent form.


12

3.2 Clinical effectiveness

Clinical effectiveness demonstrated by successful outcome of an unannounced inspection by the Quality Assurance team at NHS Wakefield District in October 2011.

The team commented: ‘We would like to congratulate you on your achievements, for a small organisation you have established robust processes in a short timescale. We were particularly impressed that novus (health) appears to be a genuinely patient centred service provider, and hope you retain this strength as your services expand.’

Clinical effectiveness demonstrated by successful outcome of an unannounced inspection by CQC in November 2011

Undertook comprehensive review of carpal tunnel assessment and treatment service throughout 2011/12

Reviewed and introduced new patient information leaflets

Reviewed and introduced new patient satisfaction forms

Reviewed and introduced new patient consent forms

Introduced a system of patient review at two days and six weeks

Undertook audit of service offered by carpal tunnel assessors

Introduced payment by outcomes for assessors

Undertook a comprehensive review of one stop vasectomy service throughout 2011/12

Reviewed and introduced new patient information leaflets

Reviewed and introduced new patient satisfaction forms

Reviewed and introduced new patient consent forms

Implemented a system of robust monitoring of sperm sample return rates

Reviewed and revised the electronic clinical information system for the one stop vasectomy service

Reviewed and revised the electronic clinical information system for the carpal tunnel assessment and treatment service

Implemented an audit cycle of clinical care 3.3 Patient experience

Introduced a Saturday clinic and late-night evening clinics to increase choice for patients in relation to location and appointment (physiotherapy)

Reviewed methods of gathering patients’ views. All patients undergoing carpal tunnel assessment, treatment and surgery and vasectomy surgery are sent a satisfaction questionnaire including a stamped addressed envelope through the


13

post. All patients attending physiotherapy are invited to complete a satisfaction questionnaire on completion of their episode of care.

Below are the results of the satisfaction questionnaires for 2011/12: Carpal Tunnel Decompression Service (March 2011-December 2011) Overall how do you rate the quality of care you received?

In relation to the symptoms that you had before the procedure, do you feel that the procedure has made:

Much improvement 75% Slight improvement 18.80%

No improvement 1.60% Symptoms are worse 3.10% No answer 1.60%

Comments from patients:

‘I was highly delighted with the service’

‘I was really pleased with the staff at the centre, they were very friendly and helpful’

‘Overall experience was excellent. The whole experience so far exceeded my expectations’

‘The staff involved with the surgery and the care afterwards were excellent’

‘A very professional team who reassured me as I was very nervous during the procedure’

‘The staff, the efficiency and the overall experience was excellent’

Excellent 67.20% Very Good 29.70% Good 0.00% Fair 3.10% Poor 0.00% No answer 0.00%

Good or better 97%


14

One Stop Vasectomy Service (Aug 2011-March 2012) Overall how do you rate the quality of care you received?

Excellent 69.60% Very Good 21.40% Good 3.60% Fair 0.00% Poor 1.80% No answer 4.00% Good or better 95%

Overall impression (venue, privacy, cleanliness)


Good or better 98% Comments from patients:

The surgeon and staff were excellent (Ash Grove)

I can’t praise Dr Dean and the team highly enough on my procedure. I was very nervous beforehand but they put my mind at ease. Everything was excellent / professional (Ash Grove)

The staff were excellent, always caring and checking I was ok. I have already recommended the procedure to friends (Ash Grove)

Really impressed with the whole experience (Normanton)

A real pleasure to see someone doing such a good job (Lupset)

Nice to see NHS working to a high standard (Normanton)

First rate service and care. Staff on the day were excellent (Normanton)


15

Community Physiotherapy Service (Oct 2011-Dec 2011) Overall, from the time your GP referred you to the time you attended for the procedure; did you feel the waiting times were?


Good or better 98% Overall how do you rate the quality of care that you received?

Excellent 92.60% Very Good 5.90% Good 0.00% Fair 0.00% Poor 0.00% No answer 1.50% Good or better 99%

In relation to the symptoms that you had before the procedure, do you feel that the procedure has made:

Much improvement 93% Slight improvement 4.40% No improvement 0.70% Symptoms are worse 0.00% No answer 1.50%

Comments from patients:

‘Could not ask for better’

‘Seen in one week - cured in three weeks!’

‘Simply carry on. First class service’

‘It was superb, really improved me mentally as well as physically (confidence)’

‘I now have a better standard of life-know how to relieve pain-better understanding of my physical condition’

‘Would recommend people to come and happy with service and staff’


16

4 Conclusion This is the first year that Novus Health has produced a quality account, and it has provided an opportunity to review our clinical services in relation to developments that have occurred during 2011/12, as well as providing an opportunity to identify clinical priorities for the coming year 2012/13. It has demonstrated that Novus Health is committed to the concept of quality in our service provision to the patients of NHS Wakefield District.

Novus Health Limited Quality Account 2011/2012 · 2.1.2 Clinical priorities for 2012 forward/13...

Documents

Transcript of Novus Health Limited Quality Account 2011/2012 · 2.1.2 Clinical priorities for 2012 forward/13...